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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209} 466.6781 <br /> .1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (ompletejinTriplicate) <br /> Application is hereby made to the San Joaquin Local Health/uMstnct for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County rdinance No.549 for sewage or No. 186'1 for well/pump and the Rules and Regulations of the San Joaquin { <br /> Local Health Distr' t..,: I <br /> Job Address , <br /> City C--Lot Size PM <br /> =Owner's Name Addre3E5 a r <br /> Ir iflitPhone <br /> Contractor's Name C� 4Iv License No. <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ w <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLb. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \ <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ £' _ J Specifications O <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout^Segal.; F� ��, _ Y T <br /> ❑ Irrigation L/ qI ^_ _ Y of rout �. <br /> pprox, Dept ❑ Eastern ^"urface Seal Installed by s , QQ <br /> Repair Work Done Type of Pump H.P:" f *t_ State Work Done Y <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth I Filler Material (Below 50) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L7 DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> �k available within 200 feet.), <br /> installation will serve: Residence— Commercial Other r fi <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water tableth <br /> SEPTIC TANK L] Type/Mfg Capacity _.No.__CQmpartriients <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. R Lengthof lines A Total length/size <br /> FILTER BEDr <br /> ❑ Distance to nearest: Well Foundations -. Property Line <br /> SEEPAGE PITS ❑ Depth Size Numbers <br /> SUMPS °❑ Distance to nearest: Well Foundation h Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which-this permit is issued, I shall not <br /> employ any person in such manner as to become subject to,workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ; <br /> The appli mus call for all re uir spec' ns. Co ete drawing on reside. <br /> Signed G Title: / 1C, Date: <br /> FOR DEPARTMENT USE ONLY � p <br /> .Application Accepted by ` t 7 <br /> Date _ Area <br /> Pit or Grout Inspection by +" i Date <br /> Final Inspection by �• ate <br /> { <br /> Additional Comments: � <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601-E:-Hazelton Ave.-P,O."Box 2t7Q9;5tk., CA 95201 <br /> -. - .. -- - �_... <br /> FEE <br /> �- <br /> INFO AMOUNT DUE I AMOUNT REMITTED CK 11 <br /> "1 RECEIVED�Y' �` P1 <br /> CASH DATE,, PERlN1T'N0. <br /> +EH 124{REV.141831 <??v <br /> EH 14-4-28 O <br />